Insanity: A Legal and Cinematic Diagnosis.

The term "insanity" has been retired from medical nomenclature for about 100 years. Formerly interchangeable with the legal term, implying unsoundness of mind, it persists as a legal determination, mainly in criminal matters. However, the most prevalent uses of "insanity" are in colloquial speech and media. We track "insanity" in medical and legal parlance, reasons for its disappearance from psychiatry, and its persistence in popular culture. During the 19th century, specific types of legal insanity fell out of favor, especially "moral insanity," referring to irresistible impulses. The term persisted, for example, in some civil cases and in criminal cases, both denoting lack of capacity. In America, early 20th century focus on disease classification and nomenclature shifted from catchall terms (such as insanity, dementia, mania, and idiocy) to medical labels (psychosis and neurosis). Psychiatrist William Alanson White led the movement to change nomenclature. In 1921, the American Journal of Insanity became the American Journal of Psychiatry. By the time White was the American Psychiatric Association president in 1925, the medical use of "insanity" had been replaced in textbooks by progressive terminology. However, variations on "insane," suggesting loss of reason without diagnostic specificity, have become a staple among film tropes.

T he medical diagnosis of "insanity" has been retired for about a century. Its essential meaning, lack of capacity, was synonymous with the legal determination of the same name and was interchangeable, in the 19th century, with alienation and dementia (Berrios, 1987). Doctors who testified about "insanity" were "alienists." Eighteenth century English jurisprudence made no nuanced distinctions among mental illnesses. Instead, a person would be excused from criminal conduct only if totally deprived of mental ability, such as that of a "wild beast" (American Academy of Psychiatry and the Law [AAPL], 2014, p S4).
As interest in differentiation among the psychoses grew, the medical term had diminishing meaning and specificity. Jurisprudence, on the other hand, could retain it, because its aim was justice, not diagnosis. Meagher (1923)

explained:
The form of insanity is a question of mental pathology and is not of particular interest to law; nor are the causes of insanity, the latter being in themselves irrelevant to the question of responsibility. Law is concerned in the consequences (conduct) resulting from insanity (p 46).
Even so, as Fingarette (1966) pointed out, because most legal definitions of insanity contain the term "mental disease," medical information is implied. Although the term is too vague to have medical meaning, courts require medical experts to provide a translation between a recognized disorder and whatever the legislature meant by mental disease. These days, however, it would not be proper for a psychiatric expert to diagnose an individual with "insanity." In Fingarette's (1966) formulation, medical information is subordinated to the goals of the law: "[M]ental disease" is not a medical term, but a moral, legal, or actuarial one. In each case the phrase "mental disease" is a term used to introduce various nonmedical issues into a context where medical expertise is expected to be a "high-visibility" source of aid (p 238).
"Insane" is formed from "sane," which has its Latin root in sanus, meaning healthy or sound; its 17th to 19th century sense includes physical integrity (mens sana in corpore sano) (Oxford English Dictionary, 2018). As the Oxford English Dictionary (2018) observes, the English use of "sane" is almost entirely restricted to "the use in antithesis with insane, which…always referred to a mental condition." Thus, "sane" means "not mad," and "insane" means "without reason." A remnant of "sound" (intact, unharmed, and safe) can be found in the law of wills, where the testator asserts being of "sound mind." Thus, to be insane, legally, refers to not being responsible for one's actions or not capable of entering into a contract (Tighe, 2005). In this article, we track terms such as "insanity" and "moral insanity" from the 19th into the 20th century. We demonstrate that, as interest grew in biopsychosocial determinants and classifications of mental disorders, the use of "insane" as a medical term receded and disappeared, whereas it persisted in legal determinations. The details of early 20th century efforts to retire the term will be illustrated by the words of leaders of that movement. Finally, we will illustrate the residual use of the term "insanity" in cinema, where its evocative power has made it a standard trope.

MEDICAL MEANING OF INSANITY
Before the late 19th century, practitioners (asylum doctors) and forensic experts (alienists) felt little need to free medical nomenclature from the nonspecific term "insanity." Fifty years after the formation of the American Psychiatric Association's (APA's) forerunner in 1844, the asylum superintendents had averted a takeover by neurology. Silas Weir Mitchell's stern chiding of the group, during the 1894 meeting in Philadelphia, came at a time of rapid change at all levels of psychiatry-etiology, classification, therapeutics, and education (Weiss, 2011). Lidz (1966) recalled the situation in the 1890s: The period of moral treatment of insanity, when hospitals were small and the superintendents knew and spoke with each patient daily, had passed. Already in 1870, John P. Gray, the dean of American alienists and head of the Utica State Hospital, was proud of having eliminated all "moral and mental" cause of insanity from his statistics because the "mind cannot become diseased, but only the brain" (p 322).
Even so, 19th century classifications described surface features of conditions for which anatomical correlates remained mysterious (Grob, 1991). In addition, because psychiatry consisted of asylum medicine, citizens disabled enough to require hospital care could simply be classified as "insane." At the time of Isaac Ray's Treatise on the Medical Jurisprudence of Insanity (1838), the distinction between congenital versus acquired causes of insanity was imported from Europe (Grob, 1991), but parsing the medical and legal meanings was unimportant. Indeed, as Tighe (2005) pointed out, Ray supported the idea that practitioners of medicine and law speak the same language.
By the late 19th century, "insanity" had become a source of confusion, without standardization useful in both medical and legal contexts. Folsom (1886) explained: The popular idea of insanity is of wild, incoherent, or crazy conduct. If maniacal, the timid or frightened young girl who would not hurt a fly, and the tottering, harmless old man if confused and partly demented, are hurried off to the asylum with the use and show of force suitable for a desperate criminal, while the victim of overwhelming delusions, because he seems clear, logical, and collected, is vigorously defended against the physician's imputation of insanity until he commits an offence against the laws, when he is fortunate if he is not treated as a criminal (p 99). Kramer (1968) reviewed the early history of psychiatric nomenclature, noting that the federal census collected statistics on persons with mental illness since 1840. At that time, "the idiotic and insane were enumerated as a single class" (Kramer, 1968, p xi), although 10 years later, unclassified mental illness was treated separately. Classification attempts did not emerge until the 1880 census, and the important developments in nomenclature were not seen until the American Medico-Psychological Association (1920) developed uniform standards. In an earlier edition (1918), there were many unself-conscious references to "the insane." Here, it appears that "insane" referred to persons requiring hospital-level care, whereas the nomenclature itself included terms such as "psychosis," "psychoneurosis," "dementia praecox," and "psychopathic inferiority." The 1920 edition changed the terms "constitutional psychopathic inferiority" to "psychopathic personality" and "not insane" to "without psychosis" (Report of Committee on Statistics, 1920). In 1921, the American Medico-Psychological Association changed its name to the American Psychiatric Association (APA) and its journal from the American Journal of Insanity to the American Journal of Psychiatry (Anonymous, 1921).
Influenced by Adolf Meyer's integrated understanding of the human condition (psychobiology), American psychiatrists regained the initiative in defining mental disorders, even if Meyer's exotic nomenclature failed (Lidz, 1966). Meyer espoused the "new psychiatry" (Lamb, 2014). He, William Alanson White, and others "abandoned the absolute distinction between insanity and sanity and the traditional model of disease upon which scientific medicine was based. Instead,…normal and abnormal mental states resided on a common spectrum" (Lamb, 2014, p 101). Although psychiatrists did not adopt many of Meyer's specific diagnoses, his focus on "reaction-types" became a basis for the first Diagnostic and Statistical Manual of Mental Disorders' (DSM's) nomenclature (APA, 1952), for example, psychotic reaction, neurotic reaction, and behavioral reaction. The term "reaction" was nearly eliminated in DSM-II (APA, 1968).

DR WHITE AND OTHERS LED PSYCHIATRY OUT OF "INSANITY"
In 1894, William Alanson White, an early career psychiatrist at Binghamton (NY) State Hospital, published "The Physical Basis of Insanity and the Insane Diathesis" (White, 1894). He recounted medieval formulations of mental illness: "We can hardly imagine more thoroughly unfortunate or unscientific ideas, yet for centuries the convictions of the most enlightened people of Europe, regarding insanity, were expressed by such phrases as 'demoniacal possession' and 'divine inspiration'" (White, 1894, p 531). He goes on: [I]t is readily seen that insanity is nothing more nor less than a symptom-complex of cortical disease. It is here then in the cortex with its almost infinite number of cells and complex nexus of intercommunicating fibres that we must look for those nervous changes which underlie the psychical manifestations of insanity (White, 1894, p 532).
Although White had adopted a materialist view of mental disorders, he had not yet considered it necessary to set aside "insanity" in favor of classifying symptom complexes.
In his Outlines of Psychiatry, White (1918), in mid-career, dispatched the term "insanity" as a medical diagnosis on page 1 (footnote 1): Insanity should not be used as a medical term at all. It is solely a legal and sociological concept and so used to designate those members of the community who are so far from able to adjust to the ordinary social requirements that the community segregates them (forcibly perhaps) and takes away their rights as citizens. Insanity is a form of social inadequacy which medically may be the result of many varieties of mental disease. Insane, therefore, means nothing more than certifiable.
In his book on mental hygiene, White (1919) succinctly reinforced the lack of clinical use of "insanity": While "insane" conduct is…the result of mental disease, "insanity" and mental disease are not interchangeable terms…[N]ot all the mentally ill by any means are insane…It is, therefore, only certain kinds and degrees of mental illness which may be classified socially and legally as "insanity" (p 65).
In White's view, each person with mental illness required customized treatment, for example, psychotherapy, somatic treatment, and other forms of rehabilitation. Failure to do so, by lumping all persons with mental illness into the "insane" category, deprived them of optimal care.
In their 1919 textbook on psychiatry and neurology, Jelliffe and White took the position that "insanity" had no place in the discussion of medical conditions. Discussing heredity and inferences drawn from family trees, they wrote: It is useless to record the fact "insane" without any definite knowledge of the particular mental disturbance. It is important to reiterate that the old Morel-Zeller view, that all mental disturbances are one disease with different stages is absurd. Insanity as a disease entity has no existence (Jelliffe and White, 1919, pp 25-26).
Jelliffe and White (1919) refer to "insanity" in the context of others' discussions, for example, Freud and Kraepelin. Later, in discussing the history of "paranoia" as a diagnosis, Jelliffe and White (1919) rejected Pinel's antiquated idea of "insanity" as a medical entity: It is based upon the simplistic conception that the brain is one organ and that it has one disease, and that disease is insanity, and not only simplistic to this extent, but that the disease may affect any part of the organ and therefore a person may be insane upon one subject, conceptions which are hardly worthy of a school boy, but yet are still held in some quarters today (p 852).
We will return to the legal application of the concept of partial insanities, in particular "moral insanity." Toward the end of Jelliffe and White's (1919) textbook, they again attacked French formulations in the discussion of intellectual disability: [F]rom the standpoint of this book, there is no such thing as insanity, at least in a medical sense, as Esquirol used that term and as other psychiatrists in the past and the present have used it. Insanity is purely a legal and sociological concept, and as such does not imply anything more than the judgment of a man's fellows on the desirability of having him live in the community (p 965). Southard (1919), of the Boston Psychopathic Hospital (Massachusetts Mental Health Center), also exerted pressure to distinguish insanity from psychosis. For example: The American Medico-Psychological Association's classification appears in short to be one dealing with the insane in the committable sense and not with psychopaths in the broader sense of modem mental hygiene…. It ought to be a task of this continuing committee, at least in the writer's opinion, to arrive at a decision whether the term psychosis should be used as equivalent to medicolegal insanity (in the sense of at least potentially committable "certifiable") or whether the term psychosis should be used in a broader sense to cover cases of mental disease which are not even potentially committable (p 332).
In 1925, White's APA presidential address included the terms "insane" and "insanity" only in quotation marks (White, 1925). Instead, he referred to hospitalized patients and to persons with psychoses. By then, robust diagnostic schemas had been considered and approved, relegating the outmoded terms to legal adjudications. However, the formulations underlying legal "insanity" persisted in forensic psychiatry.

MORAL INSANITY AND THE IRRESISTIBLE IMPULSE
Although it had long been settled that "insanity" could be applied to civil and criminal adjudications, "partial insanities," conditions that rendered a person disabled in one domain and not another, persisted. The best-known examples are "monomania" and "moral insanity," roughly discrete disturbances in thinking and emotions, respectively. Dain and Carlson (1962) observed that both European and American authorities endorsed a type of insanity in which the intellect was spared, whereas emotions and will were unbalanced, for example, Pinel's manie sans délire and, later, Prichard's "moral insanity." Under this diagnostic rubric, an individual could be excused from criminal responsibility due to inability to control behavior that the person ordinarily knew to be wrong, but to be lacking moral sense at the time in question (Dain and Carlson, 1962).
"Partial insanity" departed from the traditional conception of "legal insanity" as a disturbance of reason. Nevertheless, founders of American psychiatry, notably Isaac Ray (1838), who had been influenced by phrenology, embraced "moral insanity" among the "partial insanities" qualifying as excusing conditions for criminal behavior. In phrenological theory, any "organ" or "faculty" of the mind could be (or become) deranged, giving rise to "insane" behavior (Weiss, 2006). Advocates of moral treatment (psychosocial interventions) were likely to support the derangement of emotions in excusing criminal behavior as equal to cognitive distortions (delusions) (Dain and Carlson, 1962). The central problem with "moral insanity" was that it tended to excuse unlawful acts of which the offender was aware but could not resist the impulse to execute. This standard did not require that knowledge of wrongfulness be absent, thereby offending proponents of "cognitive insanity" (delusions) and those who adhered to traditional, Biblical values such as retributive justice (lex talionis).
Over time, the test for insanity in criminal cases shifted from derangements in both moral and cognitive domains. Prichard (1835) rejected the English tradition of equating "insanity" with the presence of delusional thinking, thus excluding other etiologies: "[U]nless the existence of this characteristic phenomenon should be proved, it would be very difficult to maintain a plea on the ground of insanity in this country, with a view to the removing culpability in a criminal accusation" (p 382). In Prichard's view, eccentricities of character and periods of excitement could give rise to impulsive behaviors, the depravity of which defied reason, but in the presence of otherwise undisturbed intellect. He said: In cases of this description the moral and active principles of the mind are strangely perverted and depraved; the power of selfgovernment is lost or greatly impaired; and the individual is found to be incapable, not of talking or reasoning upon any subject proposed to him, for this he will often do with great shrewdness and volubility, but of conducting himself with decency and propriety in the business of life (Prichard, 1835, p 4). Augstein (1996) noted that the term "moral insanity" had been used previously by Arnold and Rush to denote the perversion of morality resulting from mental illness, rather than defining a separate category. This is closer to the intent of what would later constitute "volitional insanity" (irresistible impulse) tests.
Even as "insanity" persisted as a medical term through the 19th century, divisions among psychiatrists grew in the application of emotions to the adjudication of criminal responsibility. That is, because disease concepts in psychiatry embraced materialism, there was skepticism as to whether emotions could produce an excusing condition (Dain and Carlson, 1962). The leading opponent of "moral insanity" was Dr John Gray (1858), whose platform was as editor of the American Journal of Insanity from mid-19th century through the time of the trial of Guiteau (1854-1886), President Garfield's assassin. In his critique of "moral insanity," Gray (1858) blamed Pinel, Esquirol, and Prichard for muddying the waters of criminal responsibility. For example: What Esquirol suggested by the term impulsive mania in respect to homicide, has been seized upon to cover other forms of crime, until even forgery has been claimed to be an impulsive mania, and therefore to be under the fair protection of a plea of insanity. Now if anything in the world has less that is impulsive about it, or less of any kind or description of insanity in it, than forgery, we confess to a strong curiosity to know what it can possibly be… That many insane men commit felonies, or what would be deemed such if committed by sane men, is unquestionable; but they cannot be anything less than felonies in the eye of the law, until actual insanity is proved. Insanity, which means disease or its effects, is what the law looks for, and not for any such nice distinctions as psychologists, doctors, or advocates may invent or discover. The law does not care whether the insanity is intellectual or moral; it only wants due proof of insanity, and it is satisfied (Gray, 1858, p 315).
Gray testified for the prosecution in Guiteau's trial, whereas Isaac Ray, who potentially could have countered Gray, died before the trial. Guiteau, likely psychotic, was convicted and quickly executed.
As 20th century scholars grappled with classification and terminology, Prichard's "moral insanity" was reduced to a notion of the amoral person. This degraded further into the "psychopathic personality" (Dain and Carlson, 1962) and finally equated with "antisocial personality" (Fine and Kennett, 2004). The problem was harmonization of the medical and legal meanings: "moral insanity" could simply have meant not responsible due to a deficit in volitional controls in the legal sense, whereas the clinical term took on a more ominous tone of lacking morality (depraved by nature). This labeling resulted in the criterion of "psychopathic personality" to exclude potential immigrants under federal law from 1952 until 1990 (Friedman, 2012). In this instance, the label was conflated with sexual perversion, including homosexuality, resulting in deportations when sexual preference was revealed (Friedman, 2012). Southard (1918), in this journal, argued for a new classification of mental diseases analogous to botanical designations. The scheme included 11 nonexclusive disease groups or orders: syphilitic; feeble minded; epileptic; alcohol, drug, and poison; focal brain lesions; somatic; senescent-senile; dementia praecox; manic-depressive; The Journal of Nervous and Mental Disease • Volume 207, Number 9, September 2019 Insanity psychoneurotic; and psychopathic. Southard located Prichard's "moral insanity" in the feeble-minded group, a type of "hypophrenosis," specifically, "hypophrenosis amoralia." He contrasted this term with "congenital psychopathic inferiority" (Southard, 1918, p 7). Although the subsequent history of clinical psychopathology was punctuated by useful descriptions of persons with the core features of "psychopathy," notably Cleckley's (1950) and Hare's (1993) for example, their distinctions have always equated with "aggravation," rather than "mitigation" of culpability (Fine and Kennett, 2004). Some American state legislatures have specifically excluded "antisocial personality" from the definition of "insanity" (AAPL, 2014). However, there is a minority view that the core psychopath has deficits in cognition that could be regarded as an excusing condition (Fine and Kennett, 2004). Despite ambiguity over the legal concept of "moral insanity," the idea of the irresistible impulse has not entirely been discarded. White (1923), discussing the "insanity" test as "essentially medical in character," said: The test of delusion and irresistible impulse are obviously so while the right and wrong test, although it is often defined as a sufficient knowledge to know that an act was prohibited by law, easily becomes medical when the question is raised of a state of mental defectiveness sufficient to preclude such knowledge (p 102).
Mid-20th century jurisprudence countenanced a volitional test of "insanity," the rightful heir of "moral insanity," in the American Law Institute's (ALI's) Model Penal Code. The ALI test had both a cognitive and a volitional prong, either one of which could be used, in combination with a mental disease or defect, as an excuse from criminal responsibility (AAPL, 2014). Once popular among state and federal jurisdictions, the ALI test fell out of favor after President Reagan's would-be assassin was acquitted by reason of insanity, and replaced by the federal Insanity Defense Reform Act of 1984 and modifications to state laws (AAPL, 2014). This development is reminiscent of the demise of "moral insanity" after the trial of President Garfield's assassin 100 years earlier.
Today, except for the four states that have legislated the insanity defense out of existence, all American jurisdictions permit it to be raised. Thirty-one states and federal jurisdiction, but not military jurisdiction, contain the word "insanity" within their statutes (AAPL, 2014). Because there is no uniform standard to define "insanity," wording varies. Most jurisdictions use a version of the cognitive test of whether the defendant knew that the act was wrong, based on rule established after the 1843 acquittal of Daniel M'Naghten in England (M'Naghten's Rule) (AAPL, 2014). Others use a version of an irresistible impulse test or a variation of the ALI test sometimes as an alternative to a cognitive standard (AAPL, 2014). The outlier is New Hampshire, which permits the jury to determine whether the act in question was a product or offspring of a mental disease.

INSANITY: ALIVE AND WELL IN MOVIES
There are many forms of media that address and portray mental illness. Although some educate the audience by improving acceptance of mental disorders, other representations can be stigmatizing, offensive, and inaccurate. Derivatives of the word "insane" are often used in music, literature, television, plays, and almost all forms of popular media. In this section, we will focus on the use of the term "insane" in the context of American feature films.
Film has been used to entertain, educate, and influence the masses since its inception. The term "insanity" has been used broadly, and often incorrectly, in American films. "Insanity" has been a pervasive trope in cinema. A search for the term "insan*" on the online database imdb.com returned 94 titles (refer to imdb.com for details of films referenced herein). A search for the keyword "insanity" yielded 1933 results. Neither search included the countless uses of the term within scripts.
Mental illness, psychiatry, and the cinema have been prolific sources of entertainment. The psychiatrist and film scholar Irving Schneider (1999) said, "If psychiatry had not existed, the movies would have had to invent it. And in a sense they did" (p xv). It is likely that there is a parallel for mental illness: if mental illness did not exist, movies would have invented it. In the same way that Schneider (1987) has said that movies have created their "own nosology, treatment methods, theories and practitioners" (p 996), Hollywood has created a diversity of psychopathology where diagnoses are blurred, misrepresented, exaggerated, and even fabricated. The term "insanity" is regularly used incorrectly and continues to be confused with the legal term, likely due to Hollywood's lackadaisical approach to the meaning of the term. It should also be noted that this term has significant derogatory connotations in its many appearances in film scripts.
Often, the thriller or horror genre's portrayals of mental illness are of homicidal maniacs (Goodwin, 2014) or of dangerous individuals who murder as a direct result of a mental illness. In the opening moments of Sanitarium (2013), the character Dr Henry Stenson proffers a definition of "insanity": A disease that spreads through the mind, generating twisted and deranged thoughts inside the human brain making us do awful horrendous acts much farther beyond the normal sphere of the imagination. It moves from person to person without regard to gender, race, age or creed creating unthinkable results we can neither accept nor understand. We can only try to treat or perhaps in some way comfort these poor demented souls wandering helplessly within the warped and misshapen realms of their inner worlds.
Sanitarium is one of many films portraying violence, delinquency, and aggression caused by mental illness and labeled as "insanity" without any explanation of a legal context. The setting of a psychiatric hospital is likely portrayed unrealistically to intensify the viewer's sense of horror and loss of control. Fear of being trapped in a mental hospital predates cinema, as demonstrated in reporter Nellie Bly's 1887 Ten Days in a Mad-House, in which she posed as a mental patient in New York (Smoodin, 2014); she needed a lawyer to secure her release. Even today, being wrongly committed is the subject of the horror genre, for example, in 2018's Unsane. Some of the earliest films exploited the theme of mental illness causing violence to grab the attention of moviegoers. Dr. Dippy's Sanitarium (1906) and The Maniac Cook (1909), among the first films ever recorded, portrayed mental illness used derisively for entertainment. Although these silent films do not use the term "insanity," they exploited mental illness, depicting the mentally ill committing violence. Smoodin (2014) points out that early 20th century cinema, contemporaneous with the popularization of Freudian psychology and interest in hypnosis, contained many references to these themes, especially mind control. In the silent film classic, The Cabinet of Dr. Caligari (1919), an evil asylum doctor sent out a "somnambulist" to commit serial murder. Although the plot twists to reveal that the evil doctor is part of the narrator's delusion, the film leaves an indelible mark of connection between violence and mental illness . There were early exceptions to the roughshod approach to psychiatry. In Compulsion, the 1959 film about the young murderers Leopold and Loeb and their trial, "slightly caricatured psychiatrists make valid distinctions between legal and medical concepts of insanity" (Gabbard and Gabbard, 1999, p 322).
There are other examples of more recent uses in Hollywood that demonstrate the specific use of the term "insanity" incorrectly. A law enforcement officer in Se7en (1995) explains a suspected violent murderer: "The guy's insane…Right now he's probably dancing around his room in a pair of his mommy's panties, singing show tunes and rubbing himself with peanut butter…." Similarly, the character of Patrick Bateman in American Psycho (2000) said, "I like to dissect girls. Did you know I'm utterly insane?…There are no more barriers to cross. All I have in common with the uncontrollable and the insane, the vicious and the evil, all the mayhem I have caused and my utter indifference toward it, I have now surpassed…." These quotes demonstrate the improper use of the term "insanity." However, the context of both suggests a powerful connection between "insanity" and violence.
Notably, there are certainly films that use the term correctly. In Natural Born Killers (1994), a forensic psychologist character (Dr Reingold) says in an interview: "Insane, no. Psychotic, yes. But to suggest that they're insane gives the impression that they don't know right from wrong. Mickey and Mallory know the difference between right and wrong. They just don't give a damn." However, even when the term "insanity" was used correctly in film, the viewer's understanding of "insanity" and its use can be swayed by improper context or stigmatization of the person with mental illness. For example, Se7en (1995) contains the following attorney's statement after the client carried out a series of religiously motivated homicides: "My client also wishes to inform you that, if you do not accept, he will plead insanity, across the board… We all know, with the extreme nature of these crimes, I could get him off with such a plea." The idea of a defendant "getting off " with a plea of "not guilty by reason of insanity" (NGRI), often perceived by the public as cheating the system, is a common misperception, susceptible to media manipulation (Quinn and Simpson, 2013). Indeed, without a medical test for the authenticity of a defendant's mental contents, the possibility of malingering has continued to dog criminal defenses and pervade popular culture.
Side Effects (2013) contains dialogue correctly saying "an NGRI defense is only successful one percent of the time." However, the film then misrepresents that when the "state agrees to an NGRI…. [the prosecution and defense] make a side agreement about how long she is institutionalized," rather than by examination of mental state while in the hospital (Shand and Friedman, 2014, p 272). This insidious trope portrays psychiatrists as power-hungry manipulators and the insanity defense as a commodity.
The power of film is pervasive and persuasive. The horror genre remains robust, often including inhumane institutions, evil psychiatrists, maliciously administered treatments (electroconvulsive therapy and drugs), and violent patients . Exploitation of the nexus between mental illness and violence has been especially troubling to mental health professionals-and harmful to their patients and institutions . Those with mental illness are more likely to be victims of violence, rather than perpetrators. Frequent, incorrect use of the term "insanity," although entertaining, is not educational. However, filmmakers are not beholden to standard DSM nomenclature . Worse, the practice has the potential to stigmatize Goodwin, 2014) and to create prejudice against those with mental illness generally and persons found not responsible for criminal acts specifically. On the other hand, accurate portrayals of characters with mental disorders can lessen prejudice and create empathy in the viewer. Such portrayals would not tend to use terms such as "insane" and are more likely to use DSM nomenclature in a constructive or educational manner.

DISCUSSION
"Insanity" used as a medical term lost its use when psychiatry became serious about becoming a science and developing a clinically meaningful classification system. Once again, we turn to White (1918): The term insanity includes a great multitude of different conditionsof different sorts of reactions-due to a host of different kinds of causes… [T]he impossibility of classifying mental disorders on any one basis …is at once apparent. Insanity, therefore, is not a disease; it is rather a symbol grouping for a large number of different mental diseases … The study of psychiatry is therefore primarily a study of disordered function and must be conducted not only in the autopsy room but in the psychological laboratory (pp 16-17).
The legal term still exists, seemingly impervious to challenges that mental functioning and measurement of specific capacities are properly within the domain of medicine. Because a determination of legal "insanity" is stigmatizing, ideally the criminal justice system should move past it, toward terms such as "not criminally responsible" (AAPL, 2014).
"Legal insanity," the ultimate issue in a criminal case, is a taboo matter for expert witnesses in federal jurisdiction and in those adopting Federal Rule of Evidence 704b: "In a criminal case, an expert witness must not state an opinion about whether the defendant did or did not have a mental state or condition that constitutes an element of the crime charged or of a defense. Those matters are for the trier of fact alone" (FRE, 2018). This rule is restated in the Insanity Defense Reform Act of 1984 (AAPL, 2014), the ostensive purpose of which was to prevent expert witnesses from wielding excessive authority over jury findings. Nevertheless, the authors have reviewed psychiatrists' reports in which overreaching has extended to "determining" moral wrongfulness.
"Moral insanity," on the other hand, has vanished as a legal concept. The principal reason is its conflation with immorality as a character trait, psychopathic personality, and antisocial personality disorder. The minimal idea that a person's will can be overborne by an internal emotional state, yielding to impulsive acts, is similarly unpopular. However, artifacts are found in the remaining 15 ALI-test states for the insanity defense (others have dropped the volitional prong) and in those jurisdictions using a twopronged test to support a verdict of guilty but mentally ill (AAPL, 2014).
As for the use of "insane" and "insanity" in popular culture, there is no end in sight. Mental disorders, those who have them, and those who treat them remain robust subjects for entertainment-a concerning source of misinformation. Although there is a substantial history of mental health professionals as consultants to filmmakers (Gabbard and Gabbard, 1999), it has not altered the distortions in mainstream films . This criticism, however, is not extended to documentarians who are dedicated to education over entertainment (Stastny, 1998). Although it is not inevitable that entertainment abandon accuracy, continued vigilance, via consulting to filmmakers and social media feedback, will reduce distortion and stigma. We conclude, reluctantly, that "insanity" will have an enduring home in the law and in popular media.

DISCLOSURE
The authors declare no conflict of interest.